Complaint Investigation Report

. Per facility policy, caregivers are not trained to check blood pressure, therefore the caregiver called a Medication Technician (Med Tech). Resident did not want a Med Tech and asked for a Wellness Nurse. In the time while waiting for Wellness Nurse to respond, R1 called 911 themself. Med Tech and Wellness Nurse responded at 1:35 PM just before EMT arrival. Med Tech measured R1’s blood pressure at 95/50. EMT registered two readings, the first at 109/60 pulse 79 and second at 116/63 pulse 79. R1 felt dizzy & clammy and was transported to the hospital. Per R1’s Hospital After Summary Report, resident was diagnosed with Pneumonia, COPD Exacerbation, Gerd, CAR, history of lung cancer and Iron deficiency anemia. On September 13, 2024, resident was discharged back to facility.

Interview with R1 stated that on September 12, 2024, when R1 pressed their medical alert pendant, they claimed it took 20 minutes for staff to respond. R1 claims that a female caregiver arrived at room and didn’t seem to know what to do, R1 asked for a nurse and caregiver to step out of room. R1 stated it took another 15 minutes for Med Tech to arrive.

LPA conducted Interviews with residents and staff and the following was revealed, five (5) of nine (9) residents stated that they don’t use facility pull cord/ call buttons for assistance. Four (4) of nine (9) residents stated they have used pull cords/ call buttons for assistance and stated the average response time is between 10 to 15 minutes.

During investigation, LPA made the following observations when pulling call button in Resident 3’s bedroom to test facility response time and observed staff responded to call eight minutes later. LPA pulled call cord in common area restroom located on first floor and staff responded in seven minutes.

Based on observations, interviews, and record review, it took the facility staff 26 minutes to address residents’ concerns, therefore the preponderance of evidence has been met, therefore the allegations, “Facility staff did not seek timely medical attention for resident” is deemed SUBSTANTIATED. The following is being cited on attached LIC 9099D.

An exit interview was conducted with Executive Director and copies of this report along with Appeals Rights was provided.